Coexisting avascular necrosis of the scaphoid and lunate

Coexisting Kienböck's and Preiser's Disease of the Wrist: Experience with Proximal Row Carpectomy with Dorsal Capsular Interposition Technique

BACKGROUND

Idiopathic avascular necrosis of the lunate is known as Kienböck's disease and that of the scaphoid is known as Preiser's disease. Because the prevalence of coexisting Kienböck's and Preiser's diseases is very low, standardized stages of disease and treatments are not established.

CASE PRESENTATION

We report coexisting avascular necrosis of the scaphoid and lunate in a 68-year-old woman with no history of steroids or other risk factors. We treated her with proximal row carpectomy with capsular interposition technique. A distal-based dorsal capsular flap was prepared and repaired the palmar capsule. At the last follow-up, she had no pain and had gained improved range of wrist motion. There was no arthritic change at the newly formed radiocapitate joint.

CONCLUSIONS

In the case of collapsed lunate and scaphoid with avascular necrosis, the proximal row carpectomy procedure has an advantage. Proximal row carpectomy with dorsal capsular interposition can be performed when the lunate or scaphoid cannot be saved. Arthritic changes of the capitate head and distal radius lunate facet can be covered with the dorsal capsule.

Concomitant Avascular Necrosis of the Lunate and Proximal Pole of the Scaphoid in a Thalassemia Minor Patient

Avascular necrosis (AVN) of multiple carpal bones is a very rare condition. This case report presents a patient with concomitant AVN of the lunate and proximal pole of the scaphoid that had led to severe joint space narrowing and degenerative arthritis in the radiocarpal and distal radioulnar joints (DRUJs). She was known to have thalassemia minor hemoglobinopathy. Wrist arthrodesis and distal ulna hemiresection-interposition arthroplasty (Bowers technique) for a DRUJ were offered and performed. The patient was satisfied with the clinical outcomes.

Clinical outcomes of nonsurgical treatment for Preiser disease

To elucidate whether nonsurgical treatment for Preiser disease is effective.Eight patients with Preiser disease (median age 59 [47-69] years) underwent nonsurgical treatment (median symptom-onset-to-treatment interval 8 [9-180] months). At presentation, 7 patients complained of constant pain and 1 of motion-related pain. Pain restricted wrist range of motion (median modified Mayo wrist score [MMWS] 17.5 [range 10-30]). Radiography revealed stages 1 to 3 disease (Herbert-Lanzetta classification). Median scapholunate angle was 62° (54°-75°), with 3 wrists suffering dorsal intercalated segment instability (DISI). Magnetic resonance imaging showed (Kalainov criteria) 4 stage 1 wrists (complete necrosis) and 4 stage 2 (incomplete necrosis). Two had concomitant Kienböck disease. All patients underwent nonsurgical treatment (ie, oral pain killer, immobilization, rest) and were monitored via radiographic and clinical evaluations. Scapholunate angles and the scaphoid area reduction ratio were calculated using radiography. Response criteria were the patients' subjective and objective status. Endpoint was the time from start of non-surgical to surgical treatment.Immobilization lasting 0 to 24 months (median 1.8 months) did not relieve their symptoms. Follow-up radiography showed that the disease stage had progressed in 5 of 8 wrists, with 5 wrists having DISI. The median area reduction ratio of the scaphoid was 11% (4%-52%) on anteroposterior views and 4% (-23% to 17%) on lateral views. Compared with the contralateral wrist, the median wrist flexion-extension arc was 61% (50%-79%) and the median grip strength 39%. Median MMWS score was 17.5 (10-25) - poor in 6 of 8 patients. Surgery was thus necessary in all patients.Nonsurgical treatment for Preiser disease did not improve subjective or objective outcomes and did not prevent deterioration of radiographic findings.Type of study/level of evidence: Therapeutic, Level V.

Closing Radial Wedge Osteotomy for Preiser Disease: Clinical Outcomes

PURPOSE

To determine clinical outcomes of Preiser disease treated with closing radial wedge osteotomy (CRWO).

METHODS

Seven patients with Preiser disease underwent CRWO. Two wrists had stage 2 disease, 3 had stage 3, 2 had stage 4 (Herbert-Lanzetta classification). Magnetic resonance imaging (MRI) showed that 4 wrists had stage 1 and 3 had stage 2 indicating complete and incomplete necrosis, respectively (Kalainov criteria), before surgery. Two wrists had concomitant Kienböck disease. The range of motion (ROM) of the wrists was restricted owing to pain, and median Modified Mayo Wrist Score (MMWS) was 15 points. Patients were followed after surgery with radiography, MRI, and clinical evaluation (ROM, grip strength, MMWS). Radiolunate and scapholunate angles were calculated on lateral radiographs.

RESULTS

Although there were no usual postoperative complications (eg, infection, neuropathy, distal radius nonunion), 1 patient had an extensor pollicis longus tendon rupture, and another experienced osteoarthritis with deterioration of the distal radioulnar joint. Final follow-up radiography showed that 2 wrists were stage 3, 5 were stage 5 (Herbert-Lanzetta classification). At 1 year after surgery, T1-weighted MRI showed that 2 of 6 wrists had improved from stage 1 to stage 2 (Kalainov criteria). At the final evaluation, 5 wrists had no pain, and 2 had only mild pain. Compared with the contralateral wrist, the median ROM was 80% in extension, 73% in flexion. Median grip strength was 71%, median MMWS was 75 points, and clinical results were good in 1 patient, fair in 5, and poor in 1.

CONCLUSIONS

Although follow-up radiography showed that the disease stage had progressed in 4 of 7 patients, wrist pain alleviation, retention of ROM, and improvement of grip strength were obtained. The CRWO may be an option for reducing wrist pain and retaining ROM of the wrist owing to Preiser disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Medium-term outcome of closed radial wedge osteotomy of the distal radius for Preiser disease with concomitant Kienböck disease: Two case reports and a literature review

RATIONALE

Idiopathic avascular necrosis of the scaphoid or lunate bone are known as Preiser disease and Kienböck disease, respectively. Although there are reports of avascular necrosis involving more than one carpal bone, concurrent idiopathic avascular necrosis of the scaphoid and lunate bones is rare, with only five cases reported in the English literature (including the two herein). Although the optimum treatment for Preiser disease with concomitant Kienböck disease has not been established, our cases underwent closed radial wedge osteotomy based on the evidence of satisfactory outcomes for treating Kienböck disease. We report the medium-term results of closed radial wedge osteotomy of the distal radius in two cases of Preiser disease with concomitant Kienböck disease.

PATIENT CONCERNS

We presented two patients with concomitant Preiser and Kienböck diseases. Although both smoked cigarettes, neither had any other risk factors; there was no history of trauma, although both women had jobs that required relatively heavy or repetitive manual labor.

DIAGNOSES

Two patients were diagnosed by radiographs and magnetic resonance imaging of the wrists.

INTERVENTIONS

A non-surgical strategy of splint immobilization and analgesia was not effective, and surgery was ultimately required.

OUTCOMES

Satisfactory medium-term results were achieved with closed radial wedge osteotomy of the distal radius in both cases. Although there was imaging evidence of progression of dorsal intercalated segmental instability deformity, neither of the patients was symptomatic and both declined salvage surgery.

LESSONS

We compare our cases and treatment strategy with others reported in the literature. Our cases suggest that closed radial wedge osteotomy of the distal radius is a safe and relatively straightforward means of treating patients with this rare combination of wrist disorders, and appears to obviate the need for more extensive salvage procedures.

Avascular necrosis of the proximal carpal row of the wrist. A possible complication of bisphosphonate administration

Reports of coexisting osteonecrosis of more than one carpal bone are rare. We report an osteonecrosis of the entire proximal carpal row of the wrist, started briefly after intravenous bisphosphonate administration. The use of bisphosphonates for the treatment of osteoporosis is increasing. Osteonecrosis of the jaw (ONJ) is one of the known adverse effects during chronic treatment with bisphosphonates. This case is reported to make clinicians aware of a possible causative link between bisphosphonate use and osteonecrosis of other bones.